Personalisation: On the Edge of an Innovation

Research Paper | April 2010

Personalisation
On the Edge of an Innovation

By Sarah Thelwall

Personalisation: On the Edge of an Innovation

Contents

Introduction . Implementing Personalisation no longer the why but the how? . Maintaining enough stability to keep innovating .3 TUPE and the perpetuation of a two tier workforce .4 Upgrading the infrastructure to enable smooth spot contracting The day to day challenge of implementing personalisation Barbara Martin and Brandon Trust . Barbara and her background . Independence and decision making .3 Three examples of day to day decisions - money, medication and activities .4 Barriers and risks .5 The Cornwall context .6 Development of the Brandon Trust team What needs to change if we are to scale up the provision of personalised care? 3. The need for sufficiently stable conditions (to support innovation) 3. An ability to take positive risks and front load the budget for change 3.3 The development of social markets Bibliography Endnotes

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Personalisation: On the Edge of an Innovation

1. Introduction

The wind of personalisation is blowing through public services in the United Kingdom. Its principles of individual empowerment, inclusion, and partnership are being adopted beyond the health care setting in social services, and in parts of the education and employment systems. Recognising the broad benefits of the personcentred approach beyond the niche requirements of adults with learning disabilities where it was initiated in 00 is a fantastic validation of the core principles of personalisation. But as Leadbeater and Bartlett1 note, the biggest challenge for personalisation indeed any innovation is scaling it up into a long term sustainable approach. In that sense we are still on the edge of an innovation. The Association of Chief Executives of Voluntary Organisations (ACEVO) notes that the government has set a minimum target for 30 percent of local authority-funded adult social care service users to be on a personal budget by April 0, but many authorities have gone further setting targets of 60-00 percent2. Although every council has introduced personal budgets, in reality many authorities are working at levels much lower than the

8 percent national average3. In order to achieve those bold targets, service users, commissioners and providers will be required to scale up and speed up processes of personalisation. To be successful there will need to be greater clarity on what is working well, why that is, and how to build upon it. The concept of personalisation takes people forward into a place where they can be empowered to have real control. To make this happen there are immediate barriers which need addressing. This paper looks at the leadership role that Brandon Trust (www. brandontrust.org) is playing in the implementation of personalisation of services for adults with learning disabilities. It considers the challenges that personalisation brings, both on an organisational level and for individual tenants and the people who Brandon Trust support. The paper indicates the areas where collaboration is required between policy and delivery leaders if personalisation is to become truly embedded within the provision of services to adults with learning disabilities. Based in Bristol, Brandon Trust is a charity employing nearly 000 staff

Personalisation: On the Edge of an Innovation

supporting approximately 500 people with learning disabilities. It was formed in 994 as a result of the closure of long term hospitals. Institutional learning disability services were transferred from the NHS into community residential care provision (serviced by both private and not-for-profit providers). Since 994 Brandon Trust has expanded its activities and now operates teams across Bristol, South Gloucestershire, Gloucestershire, Bath and North East Somerset, North Somerset, Plymouth and Cornwall. It has also developed a reputation as an innovator in the field of care provision for individuals with learning disabilities. Its commitment to delivering personalised services to the people it supports can be seen not only in the shifts made from large group living to small groups and individual housing options, but also in the wide range of developments in work, learning, and leisure opportunities which Brandon Trust has pioneered with its partners and the people it supports. This reflects Brandon Trusts attitude to service development the organisation develops services with rather than for the people it supports.

set out principles which assume that an individual has the capacity to make a decision, and that decisions made on their behalf should only be taken if it is demonstrated that the person lacks that capacity. Valuing People and the MCA have been key markers in the personalisation of services as they supported the shift from establishing why the agenda is imperative, to understanding how personalisation might be achieved in practice. Indeed the MCA has led to the establishment of processes for assessing an individuals capacity to make decisions which are now a regular part of planning and service development with service users and the professionals with which they work. As a provider committed to the ongoing development and improvement of support provision, Brandon Trust has positioned itself at the leading edge of service innovation. The charity started developing supported living packages in 00. Supported living enables people to live more independently by giving them greater influence over their living environment. It also gives them a stronger voice in discussions about how their support will be provided, which tends to lead to greater flexibility over the hours and types of support they receive. Supported living gives people both the rights and the responsibilities of being a tenant in their own home. This is an enormous shift away from large group residential care and nursing homes. Reconfiguring long term services in this way is presenting a number of structural challenges for Brandon Trust, their staff, the health and social care services professionals with whom they liaise, as well as the people they

1.1 Implementing Personalisation no longer the why but the how?

Whilst the 00 white paper Valuing People: A New Strategy for Learning Disability for the 21st Century set out the governments commitment to providing new opportunities for children and adults with learning disabilities, it was the 005 Mental Capacity Act (MCA) which created the leverage to ensure its implementation. Valuing People articulated its new vision based on the principles of rights, independence, choice and inclusion. The MCA

Personalisation: On the Edge of an Innovation

support. It is this change process that is the focus of this paper. As we move from pilot projects with small numbers of service users to mainstreaming personalised services and associated contracting, we should expect to see challenges of scale arising. With providers who are embracing the shift from block to spot contracts, these challenges are already evident. IThe scale up of personalisation is having a significant effect in three key areas: the ability of organisations to maintain enough stability to keep innovating; TUPE (Transfers of Undertaking, Pension and Employ ment) and the perpetuation of a two tier workforce; and upgrading the infrastructure to enable smooth spot contracting.

been piloted and proven. Both of these require a marketplace which provides sufficient stability to enable them to achieve a return on their investment i.e. a marketplace which rewards the calculated risks they are taking. A marketplace which offers spot contracts lasting no more than six months would not be ideal in this scenario. Brandon Trusts Gloucestershire contract provides an interesting comparison to the spot contract market of its Cornwall operations. Set up in 006 between Health/the Adult Social Care Gloucestershire Partnership and Brandon Trust, this 5 year contract covers the provision of services to 6 people. In theory the contract allows Brandon Trust to charge for all 6 people irrespective of the actual number of services users (i.e. they can charge for empty beds). At first glance one might suggest that this would hinder innovation. In reality the contract provides stability to the partnership which has enabled ongoing innovation in the services provided, controlling the move from a residential care model to one of individualised supported living environments. The shrinkage of the original contract is managed through annual renegotiations. These discussions provide a mechanism for negotiating whether new services are held under the original contract or negotiated separately. In this way both parties are able to manage the costs and benefits of the changes. There need to be mechanisms which minimise the length of time for which beds remain empty. The question is how is this best achieved? If we assume that both the local authority and the provider are working towards this goal then the crucial issue is around the period of time between a bed becoming empty and

This first section of this paper explores these three challenges, drawing on the experience and perceptions of Brandon Trust. Sharing how one organisation is meeting the challenges of personalisation, the paper hopes to develop insights that might be instructive for other providers working to personalise services in the social care sector, and shed light on how a national policy is being translated into action.

1.2 Maintaining enough stability to keep innovating

Brandon Trust aims to balance the ongoing innovation and development of new services with a process of mainstreaming innovations once they have

Personalisation: On the Edge of an Innovation

the services being reconfigured. In small group accommodation with budgets based, for example, on 5 people sharing night cover, it is a challenge to ensure the quality of service if one of the beds suddenly becomes empty. Providers struggle to reduce the cost base the moment the bed becomes empty, and from Brandon Trusts perspective it would make a huge difference to have external cover to support these periods of transition. The challenge of reducing the cost base by 0 percent if a bed becomes empty is not something which can be addressed by reducing cover by 0 percent you cannot, for example, have 80 percent of a staff member present. Equally the local authority is no longer making the decisions about weekly staff allocations, nor is it managing the group accommodation and therefore it needs to pass the responsibility for empty bed cost minimisation to the provider. One of the ways Brandon Trust interprets the personalisation agenda is a willingness to maintain a central ethos, while at the same time making adaptations depending on local circumstances. In Cornwall the strong emphasis from the beginning has been on individualised negotiated independent living (see Barbaras story for details, p. ). This produced the clear goal of measurable and high quality outcomes for each person. However, inherent in this model is flux and change as peoples individual circumstances are open to the ebb and flow of life. This situation is not necessarily undesirable even though it does not contain the core stability of a fifteen year change programme, as agreed and monitored with the Gloucestershire Partnership.

A structure which didnt ensure the continuity of care for users and which risked disruptions could be deleterious to the health and wellbeing service users. If a provider had to keep changing provision mechanisms in order to reduce costs this would be counterproductive both for the service users and for Gloucestershire. The contractual structure therefore ensures that the wellbeing of service users is the primary driver for both decisions about current provision and future innovation. Brandon Trust would argue that this stability of working environment has enabled it to innovate faster and to affect widerreaching change. The second challenge of the (in)stability of the environment relates to the questions who has responsibility for ensuring the ongoing development of services and how is this paid for? When we compare the two year political cycle of the local authority and councillors, to the five year strategic plans of providers such as Brandon Trust we can see the argument for putting the responsibility with the providers and thus making it one step removed from the forces of local politics. In block contracting scenarios this works well as there is a sufficiently long term view on both sides to see the benefits of ongoing service development. However in spot contracting the risk is that not only will shopping around between service providers drive down cost (as wed expect to see in any open market), but service users will be unwilling to pay for the cost of future innovations, particularly if they will not individually benefit from them. In this scenario who pays for innovation and where is it located? The classic adoption curve from innovators and early adopters through to laggards where the innovators pay more to

Personalisation: On the Edge of an Innovation

receive innovations first and the laggards pay less but achieve the benefits far later should not necessarily be applied in this setting. However the cost structure whereby innovations are more expensive when being piloted and less expensive once mainstreamed will no doubt continue to apply. Who then is responsible for covering the early and higher costs? In a scenario where the majority of service users have individual budgets and take direct payments there is likely to be a need for a separate development budget into which providers could pitch. The risk of this structure however is that, by separating innovation from delivery the processes of innovation would slow down as it could not easily be woven into the overall delivery plans (as it currently is in regions such as Gloucestershire). The history of providers such as Brandon Trust indicates that they see themselves as a key source of innovation in the sector. The shift of personnel over the past 0 -5 years has resulted in many of the key innovators moving from commissioning roles into provider roles. This leads to questions about the size of organisations capable of delivering innovation in this sector. Much of the literature cites the new-found freedom of individual budget holders to employ carers of their choice without being limited to picking from the staff and services of the larger providers. Clearly this has benefits to the service user in that they can seek out care providers who do not just possess the skills they require, but are also locallybased and conveniently accessed. Why sign up for use of a day care centre if you can work with the local community gardening team if you prefer? Anecdotal feedback the Brandon Trust care teams indicate that service users with

individual budgets do indeed use their budgets to buy more varied services. The challenge in this diversification of care is to locate the organisations that still have an overview of the service users needs and care packages in addition to detailed day to day knowledge. This allows an organisation to spot trends in needs and to innovate accordingly. Such a view is unlikely to be held by service providers working with one or two people or providing only very niche services. Key regional and national providers are well placed not only to deliver innovations based on their own experience but also to act as hubs of innovation working in partnership with more specialist providers. There is nothing terribly new in such an approach indeed Brandon Trust has a growing number of partnerships. However it is important to recognise and actively support the role providers play as innovators for the sector and to look at whether there are opportunities to extend the approach to encompass the learnings of micro or niche providers. This brokerage role has been explored in detail by Innovation Exchange, a pilot prgramme for the Office of the Third Sector in the Cabinet Office4. The challenges to the environment for innovation have also been identified by both Geoff Mulgan5 in his study of innovation in public services and by Matthew Horne6 in his review of innovation brokers for public services, in particular the lower tolerance for risk and preference for tried and tested techniques, and the need to cut across organisational and professional boundaries (ie to get beyond the professional and budgetary silos).

Personalisation: On the Edge of an Innovation

1.3 TUPE and the perpetuation of a two tier wo rkforce

TUPE is the UKs implementation of the European Union Acquired Rights Directive. It has protected the fundamental employment contractual terms of thousands of staff as they have moved from government and local authority employment to outsourced roles with independent providers. It governs their pay, hours, place of work, annual leave entitlements and sick pay. This ethical approach to the provision of a stable working environment for these staff has kept good staff in the caring profession, which has benefited the service users, as well as the staff and their families. No-one could argue with the fairness of intentions that underly this approach, particularly for those staff close to retirement who have quite reasonably planned for a retirement based on the NHS or local authority guaranteed benefits pension scheme to which theyve contributed during a long working career. The issue of the sustainability of these transfers has arisen not from the act itself but from the negotiations with providers such as Brandon Trust and in particular the liability for pensions and redundancy provision. Furthermore the transfer of staff under TUPE results in a liability which far from diminishing as staff retire is perpetuated via the Cabinet Offices Code of Practice for Workforce Matters and expands the liability to cover new, non-TUPE staff whose terms and conditions would otherwise be set by market forces. Employers taking on staff covered by TUPE face a number of contractual challenges around employment terms, redundancy terms and pension provi-

sion. These require careful negotiations with the commissioner in order to ensure that not only will the contract with the local authority cover the TUPE commitments but also to ensure that no additional legacy liabilities are transferred. For example there are cases where a pension deficit caused whilst staff were in local authority employment has been transferred to the independent provider. The appropriateness of this is questionable if no provision for the cover of such deficits is transferred, i.e. if the liability alone is transferred. Brandon Trust carries approximately 750,000 pension deficit on their balance sheet as a result of one such contract. This issue is exacerbated in smaller providers without the resources to offset such liabilities even on paper. Add this to ongoing commitments to fixed benefit pensions which demand variable contributions going forward which can be in the region of 0 percent of salary (to be met by the independent provider) and we start to build a picture of the serious sustainability issues facing organisations wishing to continue to utilise these capable and experienced staff members. TUPE creates two further challenges for providers; flexibility and cost. On flexibility, TUPE limits the extent to which providers can transform their services to respond to personalisation. Staff covered by TUPE can be moved from one work base to another, within reason, and this opportunity may be used to facilitate the re-configuration of a service, say from group care to independent living. However, the opportunity is limited by the scope to move TUPE and Code of Practice protected staff. Where more radical change is needed, this risks reducing the speed of transformation to the speed of the

Personalisation: On the Edge of an Innovation

retirement of TUPEd staff. While it is possible to achieve change to pay and terms in respect of protected staff, this requires an onerous and risky legal procedure, which may be successfully challenged. As a result, no matter the legitimacy of protecting employees pay and conditions, the result is to limit the options for making the changes that personalisation demands. The second challenge TUPE creates relates to cost, where tensions between the needs to protect employees and to reduce costs are creating perverse consequences that risk slowing the growth of personalisation. For example, where there are staff covered by TUPE, new staff will be hired on similar terms. However, in a team where there are no staff covered by TUPE, new staff can be hired at market rates. Where Brandon Trust rates for care staff might be 6-7,000 FTE (higher than that offered by individuals with direct payments) the ex-NHS (Agenda for Change) rate is likely to be in excess of 0,000. Thus the staffing costs depend on the extent to which staff members covered by TUPE are dispersed across the workforce, creating arbitrary differences in remuneration across the country. Where commissioners such as those in Cornwall are asking for substantial reductions in costs (despite TUPE commitments to inflationary pay increases), different organisations and teams therefore have differential abilities to respond, distorting the market. While protecting employees and reducing costs are both legitimate objectives, there are huge political and administrative complexities to the issue of TUPE. TUPE is being managed in a way that risks disprupting the work of organisations like Brandon Trust and reducing the ability of providers as a to

respond to the needs of citizens and public services.

1.4 Upgrading the infrastructure to enable smooth spot contracting

The systems which were put in place to support the outsourcing of block contracts from the NHS to organisations such as Brandon Trust were simply not designed to meet the needs of spot contracting. It is unsurprising therefore to see increasing transaction costs and wastage of administrative resources, as organisations try to keep the systems updated with the changes being made to users services. This challenge is exacerbated by the fact that each region uses different systems and protocols to manage budgets, invoicing and payments. The approach taken by Brandon Trust has been to develop the regional infrastructure to enable swifter responses and greater autonomy. Furthermore by training the staff to a higher level on subjects such as finance and HR practices, issues can be dealt with on the ground immediately rather than being picked up centrally at a later date (by which point there will probably have been a longer term impact on the cost of a users services). This can be seen in the restructuring of the organisation and the creation of the Locality Manager roles when compared to the old front line manager roles we can see that this post has greater responsibility for implementing services to meet local needs. This means greater budget responsibility, covering income as well as expenditure, so that it feels much more like running a business rather than reporting through a hierarchy. Working in connection with the development managers to maintain standards and

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deliver innovation and growth within a region should create a stronger business partnership internally and thus benefit the users and the commissioners by enabling a more tailored and localised offer. Also, at the point when services are being commissioned, Brandon Trust agree not just on the main budget but the levels of care and support which would be provided under special circumstances such as hospitalisation. This enables faster responses to emergent situations by the care staff with the added bonus of preventing invoices from being held up whilst approval is sought. Nonetheless the impact of these outdated systems is that organisations such as Brandon Trust incur greater cashflow issues in areas where personal budgets have been more widely implemented than in regions where block contracting is still the norm. It is therefore an issue that will need resolving before personal budgets are rolled out on a broader basis. Whilst it certainly has a cost implication for large organisations, the impact on micro providers could be a more immediate problem as they are less likely to have the ability to cover gaps in cashflow.



Personalisation: On the Edge of an Innovation

2. The day to day challenge of implementing personalisation Barbara Martin and Brandon Trust

The challenges and successes of personalisation operate on a very different level in a policy and strategy context to the way they play out in individual lives. By researching the impact of personalisation on Barbara Martins life we can very quickly see what the practical differences are and where the challenge lies. From this we can draw conclusions about where the bottle necks are likely to appear when scaling up personalised support nationally.

might be capable of taking medication of their own volition; more a case that all medication would be provided efficiently at allocated times. Yet for all that efficiency, it was not until Barbara reached her thirties that she was diagnosed as having hearing loss. Until that point it did not matter how many times she said she could not hear the issue was not addressed. Literally her voice not being heard and she could not hear the voices of others. How times have changed. After years of institutional care Barbaras life started changing. First the Care in the Community changes of the Thatcher government meant that Barbara moved to smaller group accommodation. She was accompanied by a smaller team of dedicated staff supporting a group and their specific needs. However it was only once the authorities accepted that Barbara would function better if she had her own individual accommodation that significant steps were taken to support Barbara individually rather than just as a part of a group.

2.1 Barbara and her background

Barbara Martin lives in her own home in Launceston, Cornwall. These days she makes many of the decisions about how she wishes to live her life, from choosing the colour of paint in her flat through to deciding what to cook for dinner and how to spend her money. These sound like the basics of life but for many years such decision making was undertaken without Barbaras involvement. Barbara was diagnosed with a learning disability as a child; the response was to provide institutional care in the form of large NHS long term accommodation. It was not a question of whether an individual



Personalisation: On the Edge of an Innovation

2.2 Independence and decision making

Barbara has strong views about independence and feels that the service that Brandon Trust provides must promote her rights and independence. The MCA has given providers and supporters the framework to promote and implement a change in how decisions are made. No longer are decisions restricted to the support workers and the family; instead there is a partnership which starts with Barbara herself. She makes the decisions. For example Barbara now manages her own money and, whilst her supporters will inform her as to where they feel money will need to be spent, ultimately Barbara makes the decision. In order to achieve these sorts of changes a greater proportion of the time spent with Barbara is allocated to developing her learning. Pictoral information is used in day-to-day decisions which are then passed on. The rota of support staff is now available to Barbara and the shopping list uses pictoral rather than text based lists. The first things that Barbara sought to change in order to give herself greater independence were processes which would enable her to manage her own medication and her own money and the removal of locks in the house. In prioritising these changes Barbara was choosing changes which enable her to spend more time alone.

possible scenarios with her team to equip her to deal with situations which may occur e.g. being coerced into giving money to a stranger. Barbara also manages many more aspects of her medication. Brandon Trusts role in this was to devise creative solutions that enabled such positive risks to be taken i.e. to manage the real risk of Barbara forgetting to take her medication and balancing this against the quality of life and increased independence. In this case the changes involved providing the medicines in a blister pack so that she could see how many to take and when. She also uses a light with a timer on it which alerts Barbara in the mornings to take her medication at the right time. These changes were backed by flexible support so that she had extra help to learn to make the change in the initial stages and less support once the activity had become embedded in her daily routine. The level of support needed for this and other activities is reviewed at monthly meetings between Barbara and her support team. Role play activities and discussions are included to cover safety issues and to ensure that Barbara knows how to respond in less common situations and where to turn to for help.

2.4 Barriers and risks

Lack of knowledge was probably the greatest barrier to change for both Barbara and her support team. They had all come from a background of institutionalised care. Barbara hadnt learnt the basic skills that would be required to participate in independent living; equally her supporters were not used to supporting her in these settings. Previously Barbara had little

2.3 Three examples of day to day decisions - money, medication and activities
Managing her own money comes with risks as there are situations in which Barbara would be vulnerable. Once a month Barbara will work through

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understanding of the concept of money or concepts of choice. Like many people her understanding of law was based on how they play out in her life (wearing seatbelts, not stealing, cleaning up after your dog). Barbara finds more abstract definitions of the law or even the laws that have made a difference in her life, such as the Mental Capacity Act, difficult to conceptualise. Bridging this conception gap has to come via the team who support Barbara. For these staff, having access to positive learning and development programmes which enhance their skills and knowledge is crucial. This is one of the impressive commitments that Brandon Trust has made to their teams of supporters; real, relevant, in-house training. The changing role of staff from carers to supporters has been achieved not only through education and training but also inclusion in the process of change and the development of assistive technologies. Unsurprisingly changes to core support such as that around the taking of medication and management of her mental health were seen as significant risks. The concerns by both professionals and family members were that Barbara would not be able to cope with choice and change and that her support staff might not spot if medication errors arose. The risks of change are being mitigated in two main ways. From Brandon Trusts side, when proposing a solution to a need for change identified by customers like Barbara, they will present the need, their proposed solution, and a risk analysis to their liaison point in the local authority. They have found

that presenting solutions along with the needs speeds up the process of change significantly. From Barbaras perspective by undertaking entry level education, similar to NVQs, she can demonstrate that she has acquired the skills required to undertake household activities such as using the washing machine, making a phone call or playing a DVD as well as community activities such as catching a bus, joining and using the library and so on. The response from Barbaras family has been mixed. There are those who are very happy with the changes and are pleased that Barbara is more independent. However there are also those who think that Barbaras condition and the challenges that it presents place her at such risk as to require continual support. Barbara started to manage her own medication when she transferred her provision to Brandon Trust in 007, she started to manage her own money in September 008 and the locks that had previously been placed on doors and cupboards for the kitchen, food cupboards, medicine stores and laundry areas were progressively removed between 007 and May 009. These changes have freed Barbara up to spend more time alone and to spend this time as she chooses; she now goes shopping alone, attends a gym, and has joined a walking group. By undertaking these activities rather than attending a day centre for adults with learning disabilities not only is Barbara more independent but she is known in the community and is thus safer as people in the community look out for her. Barbara is also more assertive and empowered so when unplanned situations arise, such as getting lost, then

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she is better equipped to ask for the help she needs.

2.5 The Cornwall context

Cornwall went through a series of dramatic changes in the healthcare infrastructure under the supervision of a Special Measures team from the Department of Health. One of these changes was in the way in which budgets for the care of adults with learning disabilities are managed. As a result of shifting to individual budgets Barbara was able to choose both the organisation who provided her care and the individual carers who support her. Barbara chose Brandon Trust from a shortlist of three providers and wrote out a list of names of people she wanted to support her. Why them? I liked Brandons DVD My Unique Life the woman who had the cleaning job, she was just like me. I like the way Brandon Trust wrote out the plans as if direct to me. Lynn and Nick, they came to meet me and were interested in my life. It is important to note that up until this point Barbara had no choice over who provided her support nor on the carers she saw on a day to day basis. There was simply no one through any part of the process that sought her opinion on such things. The commitment to personalise service provision has caused Brandon Trust to make significant changes in the way they operate both locally and as an organisation. Whilst Brandon Trust has a long record of high quality care provision in Bristol and the surrounding area they had not provided services in Cornwall before nor had they worked with so large a number of people with individual budgets. Instead of the head office team pitching for

a centrally awarded contract the regional director Lynn Toman and her team spent their time attending community events, discussion meetings and in one-to-one conversations with service users. This Hearts and Minds campaign resulted in Brandon Trust becoming the single largest provider of care services to adults with learning disabilities in Cornwall. Brandon Trust currently supports 93 people in the region. As Brandon Trust was new to Cornwall they had the freedom of a blank sheet of paper when it came to structuring the local team. They operate a very flat structure with very high levels of communication between the senior team members (about 0-5 people). External assessments of staff views on this have repeatedly concluded that this has made the senior team more accessible and transparent and that staff feel comfortable bringing up ideas, and articulating the needs and problems of the people they support. In the changing roles of service users, the way services are bought in a market place rather than allocated to a provider and the changing roles of staff from nurses and carers to facilitators, community builders and educators this transparency and accessibility is more crucial than ever; as both staff and service users need to easily see how to effect change. This changing role of staff was not without its challenges. In particular those with nursing qualifications and many years of experience went through a phase of feeling that their skills were no longer valued in this new market place where people wanted facilitators not carers, advisors not duty-of-care managers. However as

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the team were embedded it became clear that the core people and care skills were still very much of value, even if the ways in which they were provided were changing dramatically. A far greater emphasis is now placed on the staff role in building connections in communities, researching opportunities and facilitating education and training. The result is that both staff and service users feel much more closely connected to decision-making processes and far more involved in them.

2.6 Development of the Brandon Trust team

The Brandon Trust Cornwall team requires a far greater knowledge of the internal management processes which enable the smooth running of the contracts and budgets this means tighter financial management month to month, and greater knowledge of what causes over or under spending. They have established indicators earlier in the delivery process to flag up differences between the service level that has been contracted and actual delivery. This is particularly important when making provision for unplanned or emergency changes in the support provided for example, if a service user falls ill and requires hospitalisation. Brandon Trust has changed its contracting so that such eventualities are costed and approved at the start of a contract and only charged for if circumstances require it. The challenges of TUPE and the ways in which the ongoing service delivery and development costs are covered is a live issue in Cornwall as service users have the flexibility to change providers at six months notice. Approximately 80 percent of Brandon Trust staff

were transferred over from the local authority or the NHS. We see a market place where the service users are far more acutely aware of the market rate for the services they are purchasing, and thus more aware of the impact of increased costs resulting from highly variable yet pre-defined staff rates of pay. An example of the sorts of conversations and dilemmas this presents comes when a service user is planning a holiday and deciding who to take with them as their support staff. Depending on the staff member it could double the cost of the holiday and thus call into question whether the person can afford to go. The issues of the perpetuation of a two tier workforce and the need for organisations to build in the costs of managing a workforce, their training, and new service development is putting services under further strain now that the local authority in Cornwall have capped the rate that they are willing to pay to 5.69/hr (with exceptions being made for certain types of highly specialised provision). To date Brandon Trust has demonstrated that when they are transparent with their customers about how services cost are created, then there is definitely a willingness to pay extra for the quality that Brandon Trust represents. There is of course a limit to how much extra people will pay. The business challenge that Brandon Trust is facing is how to decide which business to pitch and which business would require a compromise of their core values and quality levels (and is thus not business worth winning).

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3. What needs to change if we are to scale up the provision of personalised care?

The goal is clear a minimum of 30 percent of local authority-funded adult social care service users to be on personal budgets by April 0. But the path to achieving this goal is not without obstructions. The drive to make personalisation a reality across social care services would be a challenge in any economic climate. In the current conditions the risk is that the momentum will slow and learning from implementation so far will not be used to strengthen service development and the mechanisms which support it. Indeed the greatest risk of all is that the current economic climate and the state of the public purse is used as an excuse for not implementing personalisation properly because of the higher early costs associated with helping people become more independent. The personalisation of support does require more intensive investment in its early stages in order to equip people with the skills needed to be more independent. However the payoffs for service users are significant increased quality of life, better physical, mental, and emotional health. For those people with a very high cost of support (the largest budget for a single individual who is supported by Brandon Trust is some 350,000 per annum) there are certainly savings to be made in the cost of support. It would be rash however to expect that the levels of savings achieved for those individuals in the top 0 percent of annual support costs will translate into savings for individuals in the middle of the bell curve of annual cost. The question therefore is how we can maintain and even increase momentum whilst taking into account the impact of the recession and its effect upon public spending. We are, after all, talking about the long term health of two percent of the UK population (roughly 985,000 in England). Until recently the approach taken in regions such as Cornwall had been held as an example, not only of the goal we should be aiming for, but as the implementation approach to follow. The changes in regions such as Gloucestershire are resulting in personalised support because of, rather than despite, the fifteen year

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contract. Clearly there are lessons to be learnt here in Cornwalls contrasting approach. Comparing these two examples, we might end up with a set of hybrid models for the implementation of personalisation. The goal would be to deliver benefits without the insecurity of very short contracts which limit the ability to recover costs invested in change. Instead the hybrids would aim to provide a combination of the ability to operate a market for services with stable high quality services which form the baseline for new innovations and service developments. By looking at the details of how personalisation is being implemented by Brandon Trust with people such as Barbara Martin, we can see that there are some very particular challenges in the scale up of personalisation. The challenge of a sufficiently stable base from which to develop innovation; the need for the freedom and the support to take positive risks that lead to an enhanced quality of life and the need for infrastructural developments to support the implementation of personalisation are all key issues to solve.

to service users, it does offer innovations in personalisation and greater transparency in terms of individual costs. If budgets are devolved too far we risk a position where no one budget holder can fund innovation themselves (they dont have enough resources to do so) yet the mechanisms for group spend have been discontinued so there is no structure for pooling resources. If liabilities are shifted from the local authority to the service providers and users we risk too much emphasis being placed on risk mitigation and insufficient focus on progression and development.

3.2 An ability to take positive risks and front load the budget for change
Developing the emotional, financial, and intellectual assets of service users means front-loading the cost of change due to the educational needs of the service-users and the need for additional support through the change. In the current climate this can feel like a greater risk than local authorities are prepared to pay for, yet we cannot afford to reduce the momentum of the shift to personalisation. There is also a need to support the families as well as the service users not least because the enabling of independence tends to feel high risk and uncomfortable as the outcomes are not assured at the outset. The challenge in terms of organisational development is that existing management structures tend to focus on the top down when the business is won centrally but

3.1 The need for sufficiently stable conditions (to support innovation)
In Gloucestershire the managed reduction of large group care ensures a stable environment for the people being supported whilst managing the cost of empty beds as efficiently as possible. So although this does not devolve the finances down to direct payments

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delivered locally. As carers shift their role and become more akin to facilitators for the service users they support, there will be a greater need for mechanisms of bottom-up feedback, ideas generation and piloting. This shift of roles from carer to facilitator will require training and development for many staff.

3.3 The development of social markets

The TUPE and Concord Acts restrictions on staff movement are presently preventing the development of a social market. The liability for redundancy costs represents too high a risk for independent and non-profit providers to consider making job descriptions, staff and structural changes to support personalisation. The very structures that were put in place to prevent a two tier workforce are in fact perpetuating it. Furthermore they are keeping the cost of provision of services above current market rates which reduces the amount of support that any individual can buy with their budget. The infrastructure for these social markets needs to be put in place so that finance systems can handle changes to billing quickly and wont hinder the cashflow to individuals or organisations who are currently shouldering a financial burden that was not intended. This means pump-priming both local authorities and providers to implement changes to financial and related systems.

Overcoming these very practical, implementation based challenges will require greater partnership between commissioners and providers and more co-ordination between departments of health, employment and education. It is however essential that personalisation is not just the ethos at the centre of individual support strategies but is built in to the infrastructure and systems which make personal support a practical reality. For as long as the systems strain under the weight of issues such as staff mobility, pensions and redundancy liabilities, return on investment risks (played out as variations in pricing between block and spot contracting) invoicing and related cashflow issues, then the risks for providers to scale in the scale up of personalised care will continue to hamper the transition. It is not reasonable to simply shift the liabilities from local authorities to independent providers. Instead far greater collaboration and partnership working is required to solve these challenges, risks and liabilities within the current economic constraints whilst maintaining a stable, high quality system which builds on the momentum and experience already established.

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4. Bibliography

ACEVO, Making it Personal: A Social Market Revolution, 009 ADASS, Putting People First: Progress Measures for the Delivery of Transforming Adult Social Care Services, 2009 Brandon Trust, Outside In: 15 Years of Brandon Trust, 009 Brandon Trust, A Short History of Brandon Trust, 008 Brandon Trust, Unique Futures: A Background Paper, 006 Brandon Trust, Unique futures: Strategic pPan 2006-11, 006 Bollard, M. (Ed), Intellectual Disability and Social Inclusion, 009 HM Govt, Valuing People: A New Strategy for Learning Disability for the 21st Century, 00 HM Govt, Putting People First A Shared Vision and Commitment to the Transformation of Adult Social Care HM Govt, Mental Capacity Act, 2005 HM Govt, Our Health, Our Care, Our Say: A New Direction for Community Services, 007 Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation Unit, 009 Innovation Exchange, Innovation Exchange: Supporting Third Sector Innovation through Brokerage, 009 Leadbeater, C., Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 008 Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, Cabinet Office, London, 003 SCIE, Personalisation: A Rough Guide, 008 UNISON, Tackling the Two Tier Workforce (Problems and Issues), 008

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5. Endnotes

. Leadbeater, C., Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 008 . ACEVO, Making it Personal: A Social Market Revolution, 009 3. According to the ADASS/LGA survey as quoted in ADASSs report on the milestones www.adass.org.ukimages/stories/Milestones%0for%0PPF%0%Final%09.0.09.pdf 4. Innovation Exchange, Innovation Exchange: Supporting Third Sector Innovation through Brokerage, 009 5. Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, Cabinet Office, London, 003 6. Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation Unit, 009



Personalisation: On the Edge of an Innovation

The Innovation Unit 28-30 Grosvenor Gardens London SW1W 0TT The Innovation Unit 2010